Hospitals in Southeast Michigan continually practice and refine plans for responding to a sudden influx of critically wounded patients caused by an incident like the shootings that took place over the weekend in El Paso, Texas, and Dayton, Ohio, which claimed 31 lives and injured more than 50 people.

Alex Rhea. M.D.

Three metro Detroit Level I trauma center staff members at Henry Ford Hospital in Detroit, Beaumont Hospital in Royal Oak and DMC Detroit Receiving Hospital say that though such an incident might stretch their resources, they are prepared.

Having a mass casualty plan and practicing for a variety of events — ranging from shootings, bombings, chemical spills, power outages or industrial accidents — is critical for a successful response if a worst-case scenario happens.

"Obviously this is not something anybody wants to take a part of, but we are large and well-prepared for anything that happens to come into our doors," said Alex Rhea, an emergency physician at Beaumont Hospital.

If 15-20 gunshot victims were transported to Beaumont Hospital, even shortly after 1 a.m. as in the case of the Dayton shootings, Rhea said the staff on duty could take care of them.

"I work midnights, and we are very well-staffed all the time," said Rhea, who is one of four attending doctors at night. "It flexes depends on how many medically ill people we have. We wouldn't have to call in extra staff unless it was extraordinary."

"We try to be" ready for a mass casualty event, said John Snider, R.N., emergency preparedness coordinator at Henry Ford Hospital. "The Joint Commission regulates hospital activity and they mandate preparedness. They call it a surge, and we have plans and procedures and trained staff ready."

A Level I center has trauma staff 24/7, can treat adults and children and has the highest capability to deal with a major event that has injured many people, among other standards.

Snider said Henry Ford's worst mass shooting intake was a few years ago when seven people were shot and brought into the ER, which is typically staffed with four or five attending physicians, 10-12 residents and 32-36 nurses, plus additional support workers to staff the 138 beds.

"We train four to five times a year" for a mass shooting event, said Snider, adding they also participate in citywide drills simulating mass casualty events such as chemical spills.

Snider said 20 gunshot wound victims at a time "would stretch our resources."

But typically once off-duty staff hear about a major event they usually come in to help. "Doctors and nurses run toward the sound of gunshots," he said.

Stefanie Wise, M.D., medical director of emergency medical services and disaster management at Detroit Receiving Hospital, said the Level I trauma center is ready in the event of a mass shooting.

"Our hospital is as ready as any trauma center can be," Wise said. "We could handle (15-20 shooting victims). If there was a significant number, we could call in more staff or bring in on-call staff or hold over staff."

With 63 beds and three trauma surgery rooms, Detroit Receiving already this year has treated 78 gunshot patients.

"We train institutionally for shootings, hazardous materials, chemical spills, power outages, evacuation procedures," said Wise, adding that Receiving is preparing for a mass shooting drill later this year.

But participating in a drill and living through a real-life incident are much different.

"(The El Paso and Dayton shootings are) a huge tragedy that I pray we never have to deal with," Wise said. "Realistically I am doing everything I can to make sure the hospital, residents, doctors and the EMS system is ready."

Detroit Medical Center

Local public safety officials take part in an active shooter training drill with DMC Huron Valley-Sinai Hospital earlier this year.

Public health crisis?

Doctors on the ground have counterparts in the medical community who have advocated for treating gun violence as a public health issue.

President Donald Trump on Monday condemned white supremacy and the "barbaric slaughter" in El Paso and Dayton. "In one voice our nation must condemn racism, bigotry and white supremacy," he said. But in his 10-minute statement he didn't call on Congress to act on any gun safety laws other than stronger action to address mental illness, violence in the media and in video games.

Earlier Monday morning, Trump tweeted that Congress should do more to strengthen background checks, but he tied the changes to changes in immigration laws he favors and that Democrats oppose.

In a statement from the American Medical Association, President Patrice Harris, M.D., called for common-sense steps to prevent avoidable deaths and injuries caused by gun violence. The AMA has declared gun violence to be a public health crisis and has called for more research, background checks and gun buy-back programs.

"The devastating gun violence tragedies in our nation this weekend are heartbreaking to physicians across America," Harris said. "We see the victims in our emergency departments and deliver trauma care to the injured, provide psychiatric care to the survivors, and console the families of the deceased. The frequency and scale of these mass shootings demands action."

Because sometimes single hospitals can be overwhelmed by the sheer numbers of injured people, regional trauma networks direct ambulances to other hospitals. For example, on Sunday Mount Sinai Hospital in Chicago temporarily stopped accepting patients because the hospital was at capacity following a three gang-related shootings in which nine people were injured and one died, CNN reported.

Technically, Mount Sinai went "on bypass," notifying the trauma network it needed to stop ambulance runs and divert traffic to other trauma centers.

Disaster training drills

In Macomb County on Thursday, a full-scale mock disaster training drill with a simulated active assailant will be conducted at COMTEC in Mount Clemens, L'Anse Creuse High School in Harrison Township and three other locations, officials announced Monday.

Participating will be the Macomb County Emergency Management and Communications, Clinton Township Emergency Management and the city of Warren Emergency Management Exercises will also occur at Clintondale High School, Clinton Township and Fitzgerald High School in Warren.

In Michigan, there are approximately 86 adult trauma centers, with 10 Level I (highest level), 23 Level II, 20 Level III and 33 Level IV, the Michigan Department of Health and Human Services said. There are also seven pediatric trauma centers, including three Level I centers.

Michigan's trauma network is divided into eight regions, with Southeast Michigan having two regions because of its size. Region 2 North includes Oakland, Macomb and St. Clair counties; Region 2 South includes Wayne, Monroe and Washtenaw counties and the city of Detroit.

Besides the four Level I trauma centers in the tri-county area — at Beaumont, Henry Ford, DMC Detroit Receiving and Ascension St. John Hospital — there are two Level I centers in Ann Arbor, at the University of Michigan and St. Joseph Mercy hospitals.

All of the hospitals in Michigan's trauma network have well-developed and well-honed disaster plans and experience enacting these plans during drills and exercises as well as during actual incidents.

Once a hospital is notified of a mass casualty event the hospital activates its disaster plan. This puts into motion a series of actions. It includes alerting necessary staff and departments on incoming patients; making room in the ER for casualties by admitting, discharging or asking existing patients to wait if medically possible.

It usually also means activating an incident command system and implementing disaster triage. Not all patients arrive at hospitals at the same time and not all arrive from ambulances. Hospital trauma chiefs must allocate staff appropriately based on the seriousness of the injuries.

Depending on the number of patients coming in, hospitals could call in additional doctors and nurses.

Often in large emergencies, ER staff can become exhausted and need to be relieved, thus necessitating additional staff from the hospital's on-call directory or from neighboring hospitals.

Since Beaumont's new trauma center opened in September 2017, Rhea said, the four trauma room bays where emergency surgery and other procedures are performed have been full several times.

"We've had a couple car accidents with multiple cars where all the trauma bays were full. Those prepare you for a larger-scale casualty" event, he said.

On Nov. 14, 1991, Beaumont's ER experienced its most traumatic event when a disgruntled worker at the Royal Oak Post Office killed four of his co-workers with a handgun and wounded several others before shooting himself.

Four of the injured people, including the shooter, were transported to Beaumont for treatment. The shooter, Thomas McIlvane, 31, was pronounced dead shortly after arrival at Beaumont.

Rhea said it is hard to comprehend being in a situation in which he would be called to treat people in a mass shooting event.

"The thing that hits closely to me, having a 6-month-old and a 2-year old daughter, is if anything like that happened to my family," Rhea said. "It just shows you how fragile life is. From a physician standpoint, it makes our job so much more important to make sure we are adequately prepared to turn around that situation."